WQ0018708_Operators Designation_20120521

Barbe Jim
•
From: Heather Adams [[e-mail]]
Sent: •Monday, May 21, 2012 3:01 PM
To: Winley, Gail
Cc: dmassey@envirolinkinc�.com; Honeycutt, Tony; Barber, Jim i
Subject: ORC Form Bay Tree Lakes .
Attachments: doc20120521091213.pdf `
Ms. Winley
Please see attached ORC Form for Baytree Lakes in Bladen County, NC,WQ0018708:.
Thank You,
Heather Adams
Director of Operations
Envirolink, Inc.
PO Box 670
Bailey,' NC 27807
Phone: [phone]
Fax: [phone]
,[e-mail]
Original Message
From: [e-mail][mailto:[e-mail]]
Sent: Monday, May 21, 2012 9:12 AM
To: [e-mail]
Subject:
CS 250ci
[00:c0:ee:7a:ab:93]

Water Pollution Control System Operator De ig4latio Form
wPcsoce
NCAC 15A 8G eO2Ol
Permittee Owner/Officer Mane LA. Ke ereeZ e'dJo lJ� � e/v . es.. ...
Mailing Address: 3 3 Wes '- -' 2 Piy ieid0 .:ied
City: ilk, ere-//. .. State: /V% , zip: 2 8 V Phone #: ( "8 6 2-
Email address: dsjodMES P.eofiti. . .
Signature:
Date:
hz—
Facility Name: Lit& Crtz$./2 ip
?ree.
I SUBMIT A SEPARATE FORM FOR EACIEI TYPE OF SYSTEM.
Facility Type & Grade:
Grade Grade
Biological WWTP SurfaceIrrigation X, N/A
Physical/Chemical - Land Application. N/A
Collection System.
Permit#: AObi 81Od'
Operator in Responsible Charge (ORC)
Print Full Name: •T i4ei pGE . 7 'd Art
Certificate Type / Grade /Number: _5I , gig 22-4/ Work Phone #: (Z ) Z-3.5'-149e)
Signature: -- 3 °f�`---- �., Date: VI `¢,1
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules and
regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 013G .0204 and tailing to do so can result in Disciplinary Actions
by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: f oy .2riewc!/i
Certifi pe / Grade / Number: S--/- 94# 01-7e'. Work Phone #: (Z- 2) Z�.5--41O® -
Signatur-.` ----. C i--.<. Date: 5//4/ll .z--
J i
"I certify that t agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to'do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission." ' r
I
Mail or Fax to:
WPCSOCC
AN Mail Service Center
Raleigh, NC 27699-1618'
Fax:[phone]
(See next page for designation of additional back-up operators. Designation of more than one back-up operator; is optional.)
Revised 1-2010